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# HEALTH BENEFITS REGISTRATION FORMStandard Form No. 2809CHAPTER 89, TITLE 5, U.S.CODEFEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1959(Read instructions on back of last page. Use only typewriter or dark pen.)CARRIER TRANS. NO.1532811. NAME (LAST)   (FIRST)   (MIDDLE INITIAL)2. DATE OF BIRTH (The month, day, year)3. Are you now married?SHAW ROBERT T. 6 19 25![check box] YES![check box] NO4. YOUR MAILING ADDRESS (NUMBER AND STREET)   (CITY AND TOWN)   (STATE)5. SEX   BOX 1147, WILLIAMSBURG, VA   ![check box] MALE   ![check box] FEMALE6. Are you covered by, or is any family member listed below cov- 7. Place an "X" in proper box to show your own annual basic salary   ered by or enrolling in, a plan under the Federal Employees   Health Benefits Act of 1959 (through the enrollment of another   United States or District of Columbia Government employee or   annuitant)?![check box] YES![check box] NOUNDER $4,000 ![check box]$6,000 TO $9,999 ![check box]$4,000 TO $5,999 ![check box]$10,000 OR OVER ![check box]1. I elect to enroll in a health benefits plan as shown below. I authorize deductions to be made from my salary, compensation, or annuity   to cover my share of the cost of the enrollment. (Copy the information requested below from inside cover of brochure of the plan you select.)NAME OF PLAN(OPTION (HIGH OR LOW))HEALTH BENEFITSPLAN.2. In space below list all eligible family members without exception. List your wife or husband first, then your unmarried children under   age 19, including legally adopted children, and report the kind   of relationship. Include also any unmarried child over 19 who became disabled before age 19 and who, because of the disability, is incapable   of self-support. (Attach a doctor's certificate for a disabled child age 19 or over.)NAMES OF FAMILY MEMBERSDATE OF BIRTH(Month, Day, Year)NAMES OF FAMILY MEMBERSDATE OF BIRTH(Month, Day, Year)Wife orHusband[1][6][2][7][3][8][4][9][5][10]3. If you are a female (employee or annuitant)--does the family listed above include a husband who is incapable of self-support.   support by reason of mental or physical disability which can be expected to continue for more than one year? (If answer   is "Yes," attach a doctor's certificate.)   ![check box] YES   ![check box] NOPLACE AN "X" IN ITEM 1 OR ITEM 2, WHICHEVER APPLIES (AND ANSWER ITEM 3)1. I elect not to enroll in any plan   under the Health Benefits Act.   ![check box]3. The reason for my action is (Place an "X" in proper box)   (a) I am covered by a plan under the Health Benefits Act through the enroll-ment of my husband, wife, or parent.2. I elect to cancel my present enroll-   ment in the Health Benefits Act.   ![check box]   (b) I am covered by a health insurance plan which is not under the Health Benefits Act.I desire to change my enrollment as shown by the enrollment card I have completed.1. Enrollment code number of present plan2. Enrollment code number of plan desired.3. Date of event which permits change   MONTH   DAY   YEARRobert L. Shaw June 20, 1965WARNING: - Any intentional false statement in this application or willful misrepresentation relative(SIGNATURE OF EMPLOYEE OR ANNUITANT)(DATE)thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment ofnot more than 5 years, or both.(18 U.S.C. 1001.)1. NAME AND ADDRESS OF EMPLOYING OFFICE2. DATE RECEIVED IN   EMPLOYING OFFICE3. EFFECTIVE DATE OF   ELECTION4. PERSONNEL OFFICE (SIGNATURE)5. DATE (MONTH, DAY, YEAR)Triplicate - To Employing OfficeSF2809 (REV. 9-68)